When do individual health insurers have to sell me a policy?

In Colorado, your ability to buy an individual health insurance policy depends on your health status.

· In general, insurers that sell individual health insurance in Colorado are free to turn you down because of your health status and other factors. When applying for individual health insurance, you may be asked questions about health conditions you have now or had in the past. Depending on your health status, insurers might refuse to sell you coverage or they may offer to sell you a policy that has special limitations on what it covers. If you are turned down or offered a policy with reductions or restrictions, you may be eligible for CoverColorado coverage.

However, under no circumstance can you be turned down, charged more or face a pre-existing exclusion period because of your genetic information. Genetic information includes the results of a genetic test and your family history of health conditions.

· If you are HIPAA eligible, CoverColorado is your only guaranteed source of individual health insurance.

· In Colorado, newborns, adopted children, and children placed for adoption are automatically covered under the parents’ individual health insurance, if the plan covers dependents. Generally, the automatic period of coverage lasts for the first 31 days following the birth or adoptions, however the length may vary policy to policy. The insurer may require that the parent enroll the child within the 31 days in order to continue coverage beyond the 31 days.

· Under Colorado law, your unmarried, disabled child may remain covered under your fully insured group plan into adulthood, if the plan covers dependents. In order to qualify, your child must be medical certified as disabled and dependent of the parent.

· If you are self-employed, you may qualify to buy a small group health plan as a business group of one. (see Small Employer or Self-Insured Person)

What will my individual health insurance policy cover?

· It depends on what you buy. Colorado does not require health insurers in the individual market to sell standardized policies. Health plans can design different policies and you will have to read and compare them carefully. However, Colorado does require all health plans to cover certain benefits – such as mammograms, prostate cancer screening, and diabetes treatment. Check with the Colorado Division of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

· Individual health insurers can impose elimination riders. This is an amendment to your health insurance policy that that may permanently exclude a specific, named health condition you may have or have had in the past. In Colorado, elimination riders may only exclude specific health conditions (such as asthma) from coverage, not the body parts or systems they affect (such as your respiratory system).

· Individual insurers can also impose pre-existing condition exclusion periods. In Colorado, an individual market insurer can apply a pre-existing condition exclusion period for up to 12 months.

The definition of pre-existing condition is different under individual health insurance than under group health plans. Individual health insurers can count as pre-existing any condition for which you received medical advice, care, treatment, or diagnosis in the 12 months prior to purchasing coverage. This is called the objective standard.

Pregnancy may be considered a pre-existing condition in an individual health insurance policy. However, genetic information cannot be used as a basis for a pre-existing condition.

· If you make a claim during the first two years of coverage, the insurer can look back to see if the claim is for a condition that would have been considered a pre-existing condition. If the insurer determines that the condition is a pre-existing condition, it can refuse to pay for expenses for that condition.

· Like fully insured group health plans, individual health insurers in Colorado must give you credit for prior continuous coverage. Coverage counts as continuous if it is not interrupted by a break of 90 or more days in a row. However, prior coverage will not be credited against elimination riders.

What can I be charged for an individual health insurance policy?

· Generally, in Colorado, there are no limits on how much you can be charged for an individual health insurance policy. Individual premiums can vary due to health status, age, gender, family size, and other factors. However premiums cannot vary based on your genetic information.

· When your policy is renewed, the premium increases will be based on the claim experience of the pool of people who bought the same policy you bought. This means that your rates will depend on the health of the entire pool of people with the same policy, not just on your health alone. However, regardless of the claim that you have made, your premiums can increase on other factors, such as your age, or the length of time you have held the policy.

Can my individual health insurance policy be canceled?

· Your coverage cannot be canceled because you get sick. This is called guaranteed renewability. Generally, you have this protection provided that you pay the premiums, do not defraud the company, and, in the case of managed care plans, continue to live in the plan service area.

However if you make a claim during the first two years of coverage under your policy, the insurer might re-investigate information you provided during the application process to determine whether you made a misstatement. If so, the insurer might try to take back your policy and void coverage altogether.

If you become involved in one of these “post-claims” investigations, be sure to call the Colorado Division Of Insurance to learn more about your rights.

· Some insurance companies sell temporary health insurance policies. Temporary policies are not guaranteed renewable. They will only cover you for a limited time, such as 6 months. If you want to renew coverage under a temporary policy after it expires, you will have to reapply and there is no guarantee that coverage will be re-issued at all or at the same price.